2017 Qualified Health Plans Educational Webinars. Frequently Asked Questions (FAQ) from sessions held week of: 12/19/ /23/2016

Transcription

1 2017 Qualified Health Plans Educational Webinars Frequently Asked Questions (FAQ) from sessions held week of: 12/19/ /23/ You have referred us to the Blue Cross of Idaho website to check the patient s PCP. If a patient updates their PCP, will this change show immediately or will it not be updated until the first of the following month? 2. We are a specialist. How will we know if we have gotten a referral from the patient s PCP? 3. When viewing the Hometown East QHP page on the provider portal, I do not see Madison Memorial as an option for hospitals. Why? 4. Are there new contracts that need to be signed for any of these new 2017 QHP plans or will our existing contracts include these plans? 5. For specialties such as physical therapy, would we need to check the JIVA portal for referrals before providing treatment or is this just for specialty physicians other than PCPs? 6. We are a specialty clinic with a satellite office that is located in another network. Can our Hometown East patients be seen in the clinic that is located in the Mountain View network or do they have to obtain all their services only in the Hometown East office? 7. Could a patient choose an out-of-network specialist and be seen with a referral from the PCP even if there is an in-network specialist? 8. What about lab tests? Are we restricted to which independent labs we can use? 9. If I m a provider in the Portneuf area and a patient has the Mountain View network plan, would my services be considered out-of-network? 10. If a specialist has a referral from the PCP and that specialist will be doing a procedure in a facility other than their office, will a prior authorization for the specialist s service be needed? 11. Once we have completed entering a referral, is there an option to view or print a copy of the referral? Will there be any reason to keep track of completed referrals or will they always be available on the portal? 12. We have had several patients that received letters saying the Blue Cross of Idaho is going to be partnering with Saint Alphonsus and that their plan will be automatically switched to the Saint Alphonsus Health Alliance network unless the patient chooses otherwise? What does this mean?

2 13. If we are not the patient s PCP but we are an OB/GYN seeing them for pregnancy and they need a referral to a specialist, do they need to go back to their listed PCP or are we able to send that referral? 14. Does the referral number need to be included on a claim? 15. How long will it take for a referral to be approved? 16. If we forget to send the referral via JIVA and we only send the patient s records directly to the specialist, will Blue Cross of Idaho notify us to do the JIVA referral? 17. Our physicians will be contracting with and will have a clinic location in two adjoining networks. Can patients be seen in either of the clinics, as long as hospital care is provided at the contracted hospital? 18. If a patient is seen in our emergency department and then needs transport to Kootenai Medical Center, will they need a referral for the care provided at Kootenai Medical Center? 19. If we receive a referral for a patient and we need to referral them onto a different specialist, are we able to make the referral or will the new referral have to come from the PCP? 20. Are these webinars recorded and will they be available to view online at a later time? Answers 1. You have referred us to the Blue Cross of Idaho website to check the patient s PCP. If a patient updates their PCP, will this change show immediately or will it not be updated until the first of the following month? When checking a patient s eligibility, a list of their PCPs will display as well as the effective date and termination date for each PCP. If a patient changes to a new PCP, the new PCP will not become effective until the first day of the following month and their PCP list indicate that. Currently the member search tool on the provider portal does not have the ability to view prospective eligibility and benefits. Providers can contact the Blue Cross of Idaho Provider Contact Center to verify prospective benefits at or Eligibility, benefits and new ID cards can be verified online on or after January 1, We are a specialist. How will we know if we have gotten a referral from the patient s PCP? If a specialist is seeing a patient with a 2017 QHP plan, they would need to review the provider portal to see if the PCP has entered a referral. To search for a referral, log onto the provider portal, hover over the Authorizations & Notifications tab and select Tailored Network Referrals from the dropdown list. Next select the blue Launch button towards the bottom of the screen. In the next screen, select Search Referrals. You will then be prompted to enter the patient s last name, first name, and date of birth and then select Search. Existing referrals would show either a pending or approved status.

3 3. When viewing the Hometown East QHP page on the provider portal, I do not see Madison Memorial as an option for hospitals. Why? The provider list on these network pages is not an all-inclusive list but rather a general overview of providers in that network. For more detailed information, you may refer to the Provider Directory and search for providers by name or specialty type. 4. Are there new contracts that need to be signed for any of these new 2017 QHP plans or will our existing contracts include these plans? If you are a PCP or specialist provider that is already a contracting provider with Blue Cross of Idaho, you would have received an amendment to your existing contract to explain that you are now part of the network(s) in your geographical location. If you are ancillary provider, for example, a DME, therapy, or counseling provider, you would have received a letter from Provider Network Management asking if you wanted to specifically opt out of these networks. You may contact your provider relations representative to confirm your 2017 QHP contracting status. 5. For specialties such as physical therapy, would we need to check the JIVA portal for referrals before providing treatment or is this just for specialty physicians other than PCPs? Physical therapists services will not require a referral as long as they are in-network with the member s plan. Therapy services that are not available within the patient s network would require an approved gap referral. For a list of services that do not require a referral, select here. 6. We are a specialty clinic with a satellite office that is located in another network. Can our Hometown East patients be seen in the clinic that is located in the Mountain View network or do they have to obtain all their services only in the Hometown East office? No. Approved specialist referrals are based on tax identification numbers (TIN). If the satellite office bills under the same TIN as the primary office location then services provided in the satellite location will not require an additional referral. 7. Could a patient choose an out-of-network specialist and be seen with a referral from the PCP even if there is an in-network specialist? There would have to be a special circumstance for Healthcare Operations to approve an out-ofnetwork specialist when there is an in-network specialist option available. This situation would need to be reviewed on a case-by-case basis. If the patient still chooses to see an out-ofnetwork specialist without an approved gap referral, that specialist s claims would be applied to the patient s out-of-network benefits. 8. What about lab tests? Are we restricted to which independent labs we can use? No. Laboratory services do not require a referral. Referrals will not be required and in-network benefits will apply for the following provider types: anesthesiologist (exception-pain management), independent laboratory, radiologist (exception-interventional radiology services) and pathologists

4 9. If I m a provider in the Portneuf area and a patient has the Mountain View network plan, would my services be considered out-of-network? If you are a PCP in the Portneuf Quality Alliance (PQA), you could not be a PCP for a patient with a Mountain View network plan. If you are a specialist in the PQA network and your specialty is not available within the Mountain View network, you may treat the patient if there is an approved gap referral in place. 10. If a specialist has a referral from the PCP and that specialist will be doing a procedure in a facility other than their office, will a prior authorization for the specialist s service be needed? Remember that referrals send a patient from a PCP to another provider. Prior authorization is a pre-service request to validate the medical necessity of that service. If the service that the specialist will perform requires a prior authorization, the specialist must obtain that prior to rendering the service. This process includes indicating which facility the procedure will be performed in. For a list of services that require prior authorization, please select here. 11. Once we have completed entering a referral, is there an option to view or print a copy of the referral? Will there be any reason to keep track of completed referrals or will they always be available on the portal? Yes. Once the referral process has been completed, there will be an option to print a copy. A patient s referral history will be available in the JIVA system on the provider portal. Simply perform a Search Request, enter in the patient s last name, first name and date of birth in the appropriate fields and select Search. A list of completed referrals specific to your provider and their statuses should appear just below the patient s information. The JIVA system can show at least a five year referral history. 12. We have had several patients that received letters saying the Blue Cross of Idaho is going to be partnering with Saint Alphonsus and that their plan will be automatically switched to the Saint Alphonsus Health Alliance network unless the patient chooses otherwise? What does this mean? This letter would indicate that those patients had a QHP PPO plan and our QHP PPO products will not be offered in That letter was to notify the patient that Blue Cross of Idaho has cross-walked their benefits to the 2017 QHP plan that most closely reflects their current benefits. Because that patient had primary chosen Saint Alphonsus providers, they will be cross-walked into the Saint Alphonsus Health Alliance network. Patients have the option of keeping that plan or contacting Blue Cross of Idaho to choose a different plan. 13. If we are not the patient s PCP but we are an OB/GYN seeing them for pregnancy and they need a referral to a specialist, do they need to go back to their listed PCP or are we able to send that referral? The patient s specific PCP would need to issue the referral to the specialist. This process is part of the intent of the QHP plans where the PCP is the cornerstone of the patient s care and needs to stay well informed of the specialty care their patients need.

5 14. Does the referral number need to be included on a claim? No. However, non-pcp providers will need to enter the referring provider s name and National Provider Identification (NPI) in box 17 of the claim form or box 17b of the electronic claim submission. Blue Cross of Idaho will be tracking referral patterns internally. 15. How long will it take for a referral to be approved? Referrals from a PCP to an in-network specialist will be approved in a matter of minutes. Gap referrals or referrals to an out-of-network provider must be reviewed by Healthcare Operations prior to approval and may take up to days. 16. If we forget to send the referral via JIVA and we only send the patient s records directly to the specialist, will Blue Cross of Idaho notify us to do the JIVA referral? No. Remember that the types of referrals we are discussing in our webinar presentations are the referrals needed for the patient to receive the best benefits of their insurance plan. A referral with medical records attached with the intent to notify a specialist that a patient needs to schedule an appointment with them will not negate the need to enter a referral on our provider portal. Blue Cross of Idaho would recommend that PCPs enter the referral into the JIVA system first and then send medical records to the specialist. 17. Our physicians will be contracting with and will have a clinic location in two adjoining networks. Can patients be seen in either of the clinics, as long as hospital care is provided at the contracted hospital? Yes. Regardless of clinic location, if the physician is contracting with the network listed on the patient s card, benefits will process in-network. Keep in mind, specialist s services will still require a referral. Facilities must also be contracting with the network listed on the patient s card for their services to be processed as in-network. 18. If a patient is seen in our emergency department and then needs transport to Kootenai Medical Center, will they need a referral for the care provided at Kootenai Medical Center? No. Emergent or urgent care will not require a referral. In the event that additional specialty follow up care is needed on an outpatient basis after that emergent situation has ended, then a referral would be required. For a list of services that do not require a referral, select here. 19. If we receive a referral for a patient and we need to referral them onto a different specialist, are we able to make the referral or will the new referral have to come from the PCP? Remember that the patient s PCP is the cornerstone of their healthcare and needs to stay informed of the patient s specialized care. The original specialist would need to contact the PCP and notify them of the need to refer the patient to a different specialist. It would be up to the discretion of the PCP whether the patient would need to be seen in the PCP s office first or if the new specialist s referral could be generated based on the original specialist s request.

6 20. Are these webinars recorded and will they be available to view online at a later time? Each webinar is recorded and a copy of the recording will be made available upon request to those who have attended. To request a copy of the webinar, please reply to either your invite to the WebEx or to the survey request sent at the end of each week. Special Reminder: The changes discussed above only apply to the Affordable Care Act (ACA) plans purchased through the healthcare exchanges, insurance brokers, or through the shopper s page on the Blue Cross of Idaho website for individual members and their family. Large commercial insurance plans that are furnished through employer groups such as Albertson s or Simplot for example, will not be affected by these changes.